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HomeMy WebLinkAbout4151 MAIN STREET , i . , . . , . , , . .„, .,, . . .. .. .. . . . ... , ,.. , -...\-. ,. . . , . . . . . .. . . . . . . . . J. . . /�J , , . , . . .„.. . . . . ,. '� : • 'e' ram.' , . ,. , . , . , , . • , ... . . .4 . . . : . .. . . 4 • • .. - ., - p. n o . .. • u r ,rr .tip • • - • ¢ • .is :. :r - a . i M1 , F;r • , . n .: . c.. a .n a. I -a " :. . • .. .. . , r, , �, ,, Town of Barnstable *Permit# ,P-�7-t fl1 /kc.,,,,,,, Tres 6 months from issue date * s;. Regulatory Services /..s-� -- ABLE. * 414ER. 1®,s. 44*##f s& Richard V.Scali,Director 1 Fi4 � ° ` BuildingDivision JUL191017 AB Paul Roma,Building Commissioner TO WA/ 200 Main Street,Hyannis,MA 02601 TO 11. N , -l H www.town.barnstable.ma.us '1 � � Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY / Not Valid without Red X-Press Imprint Map/parcel Number 3 ) Q-i n Prop .. Address_ Lit S— I a 1'Ul s)• i'-i O A is aYwAix-ei Om no`rp 10 Residential Value of Work$ 2_0 0 0 0 Minimum fee of$35.00 for work under$6000.00 I Owner's Name&Address V I OrdAk.. 6-IJYt( 643er H s1 M C/ /►'l ST• C aim j-6.0 is • Contractor's Name cr.(pRcu 0 a Li I,I . Telephone Number ( O t 7 6 —6.6 S Home Improvement Contractor License#(if applicable) (3 t VI I Email: C 1°/h/IN/1-IN\ COP 611W C1l 406 0' 4 .C Construction Supervisor's License#(if applicable) (3"! / G c(7 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ m the Homeowner • I have Worker's Compensation Insurance Insurance Company Name Pr%-6 C. thiCLA 114/ eitS Workman's Comp.Policy# • LJ GL -7)O s-0 Q A (el°l [6/� Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to AISC (6iS J Sd cei ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) / /5 K ❑ Re-side � ? ❑ Replacement Windows/doors/sliders.U-Value ,.3 d (maximum.32)#of windows l3 #of doors: *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors lF it nee&Construction Supervisors License is require SIGNATURE: civ , 0 ., C:\Users\decollik\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\L7U69LF2\EXPRESS(2).doc 1 V 01/25/17 r O Cas BARM9'tABI s irt 0 Town of Barnstable Regulatory Services Richard v.Scali,Director Building Division Paul Roma Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, U� h— I\ARA 6495 , as Owner of the subject property hereby authorize S O fir.) (,O'eV ,I^3 to act on my behalf, in all matters relative to work authorized by this building permit application for: 141€1 ih,bi tJ 6.14 CUM ill /9-0,01.6 (Address of Job) l 5 i5 . /1 Sign e of Ow ' Date V3 EnirNi 0011 Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. c:\Users\decollik\AppDateLocal\M crosoft\Windows\INetCacheTontem:0utlook\L7U69IF2\E7 PRESS(2)doc 01/25/17 r Cfite V 1 _.: � /Qac# uoet� . Office of. Consumer Affairs and B smess Regulation a 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contactor Registration 'M---= Registration: 131841 r fi Type: Private Corporation ~-r M Expiration: 9/26/2018 Tr# 419291 1 CENTRAL CAPE CONSTRUCTION`CO INC. T 1- STEPHEN DEVLIN ( - . / \; 820 MAIN ST. COTUIT, MA 02635 ,,,.,; f �"' � `£Z" .. Update Address and return card.Mark reason for change. 4P " 0 Address 0 Renewal 0 Employment 0 Lost Card SCA 1 0 20M-05/11 Massachusetts Department of Public Safety V Board of Building Regulations and Standards License: CS-047993 Construction Supervisor . ,�,,, (1 . STEPHEN J DEVLIN 820 MAIN STREET . r CQTUIT MA 02635 INI..fn � Expiration: Commissioner 02/0412018 The Commonwealth of Massachusetts of Department Industrial Accidents .. . """" Office of Investigationssiwt ,,—,..i.1L;r: .....7411MIlmrs. 600 Washngt.on Street . ,. ,_' Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please-Print Legibly Name (Business/Organization/Individual): C`21 Jl1' c/ qip e, Cl W fi.ucq i 110 Address: c V1/1.614) S -, City/State/Zip: COTvt1 ) 11))1 OL63c Phone#: dr rn 6 a(0 �e you an employer?Check the box:appropriate - 1. I am a employer with r 4. I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub contractors 6. New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp.insurance.t required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.]f c. 152, §1(4),and we have no p �� employees. [No workers' 13. Other e/'9L9tcvlcrl- (Ail)4GWS comp. insurance required.] ' *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: S Q C W-Q/1 -ElL.c y eicS Policy#or Self-in .Lic.#: U'C C 0 O -0 O 1 M ation Dater q(L.Iiii) Job Site Address: LI M RT. 6/1 ('1941 & . City/State/Zip: C(Amin p,AAip, 'P4d2 .Cr? Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th ains andpenalti - erjury that the information provided-above is true and correct. Signature: Date: q i.) Phone#: JU r )7d� I0 aO Official use only. Do not write in this area,to be completed by city or town official - City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Client#:38438 2CENTRALCA ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MM2DD/YYYY) 05/15/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder-is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Dowling&O'Neil Insurance Ag PN ONE Fax (MC,No,Ext):508 775-1620 (A/C,No): 5087781218 973 lyannough Rd,PO Box 1990 EMAIL Hyannis,MA 02601 ADDRESS: 508 775-1620 INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:NGM Insurance Company 14788 INSURED INSURER B:Associated Employers Insurance 11104 Central Cape Construction Company,Inc. 820 Main Street INSURER c: Cotuit,MA 02635 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTRR TYPE OF INSURANCE ADDLN SUBR POLICY NUMBER POLICY EFF POUCY EXP LIMITS (MMIDDIYYYY) (MM/DD/YYYY) A GENERAL LIABILITY MPI9764Q 11/14/2016 11/14/2017 EACH OCCURRENCE $1,000,000 PREM X COMMERCIAL GENERAL LIABILITY ISES(EaE acMun0ience) $500,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 7 POLICY jECOT- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC50050091992017A 05/1412017 05/14/2018 X we sTATU- (RH AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY EXCLUDED,ECUTIVE Y fYN N/A E.L.EACH ACCIDENT $500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) "Workers Comp Information" Voluntary Compensation Proprietors/Partners/Executive Officers/Members Excluded: Steve Devlin,Pres./Treas. (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Mashpee Commons LP SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 1530 ACCORDANCE WITH THE POLICY PROVISIONS. Mashpee,MA 02649 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD #S190898/M190897 LS1